kansas infant toddler services individualized family ...· kansas infant toddler services...

Download Kansas Infant Toddler Services Individualized Family ...· Kansas Infant Toddler Services Individualized

Post on 17-Feb-2019




0 download

Embed Size (px)



Page 1 of 20

Kansas Infant Toddler Services

Individualized Family Service Plan (IFSP)

Under Part C of IDEA, the IFSP is required to enhance the capacity of families to meet the needs of children birth to three who have developmental delays or exceptionalities.

Child and Family Information 1. Childs Name: Kicho D. Jung 2. Date of Birth 02/01/2011 3. Gender: Female

4. County of Residence: Shawnee 5. Primary Language: Mandarin Interpreter needed Yes No

6. Parent/Guardians Name: Lan Jung 6. Parent/Guardians Name: Po Wang

7. Relationship: Mother 8. Child Resides at this address:

Yes No 7. Relationship: Mother

8. Child Resides at this address:

Yes No 9. Mailing Address: 5556 NE Shawnee Fountain Rd. 9. Mailing Address: 5556 NE Shawnee Fountain Rd.

10. City/State/Zip: Topeka KS 66546 10. City/State/Zip: Topeka KS 66546

11. Phone Number(s):

(785)789-6892 Work Home Cell




Work Home Cell




Work Home Cell

11. Phone Number(s):

(785)875-8754 Work Home Cell




Work Home Cell




Work Home Cell

12. Parent Email Address: kicho@yahoo.com 12. Parent Email Address: po@gmail.com

13. Race: Asian 14. Ethnicity: Non-Hispanic 15. Resident School District (USD #): 675

16. Alternate contact: John ny Anderson 17. Mailing Address: 5558 NE Shawnee Fountain Rd.

18. Relationship to child: Other 19. City/State/Zip: Topeka KS 66546 20. Phone Number:

(785)789-3232 Work Home Cell

21. Email Address: jman@paylessshoes.com 22. Child Resides at this address: Yes No

23. Identification Number (KIDS ID): 9057465000 24. Case Number:

25. Interim IFSP: Initial IFSP: Annual IFSP: Review IFSP:

Important Dates 26. Part C Referral Date: 01/12/2012 27. 45 day Timeline Due Date: 02/26/2012 28. Part C Referral Source: Physicians/Doctors 29. Source Name: Denise Blankenship, Social Worker, Children's Mercy Phone Number: (816)334-2003 30. Initial Eligibility Date: 01/19/2012 31. Initial IFSP Date: 02/03/2012 32. Current IFSP Date: 02/03/2013 33. Six-month IFSP Review Due Date: 08/03/2012 34. Annual IFSP Review Due Date: 08/03/2013 35. Part B Referral Date: 08/01/2013 (actual date of referral, including call to Part B and ITS database entry) 36. Child transferred from another tiny-k program: Yes No 37. Date referred to our local tiny-k program: 01/12/2012 38. Date IFSP Accepted by our program: 00/00/00 39. Transition Conference Date:



40. Transition Plan Required: Yes No (because the child is not within 9 months to 90 days of turning three)

Page 2 of 20

Childs Name: Kicho D. Jung DOB: 02/01/2011 IFSP Date: 02/03/2013

Eligibility for Part C Services

The evaluation and assessment of each child and the determination of the childs initial and ongoing eligibility for Part C Early intervention services may include the use of informed clinical opinion. Eligibility determination is a team decision.

1. Your child was evaluated by a multidisciplinary team and is eligible for Part C Services for the following reason: A Developmental Delay of 25% in one developmental area or 20% delay in 2 or more developmental areas

Automatically Eligible due to established risk for developmental delay (identify): Spinal muscular atrophy (SMA)

Informed Clinical Opinion (check and provide explanation if this is the only method used for determining eligibility although clinical opinion must be used throughout evaluation and assessment):

2. Team members determining eligibility (at least two): Name (1): Jade Bell

Discipline: Physical Therapy Name (2): Lori Reed-Rogers

Discipline: Early Intervention Teacher Name (3):


Name (4):


Family Service Coordinator Information

Family Service Coordination is provided to all families enrolled in early intervention services. A Family Services Coordinator will help you identify and access community resources and supports that you and your child may need, based on your current priorities.

3. Family Service Coordinator: Steven Lange

4. Agency: Shawnee County tiny-k Services

5. Agency Address: 2701 SW Randolph Ave.

6. City/State/Zip: Topeka KS 66614

7. Phone Number: (785)232-0597 Ext: 331 8. Work Cell

9. Email Address: slang@tarcinc.org

Page 3 of 20

Childs Name: Kicho D. Jung DOB: 02/01/2011 IFSP Date: 02/03/2013

Summary of Relevant Health Status

Primary Care Information 1. Primary Care Provider/Medical Home Name: Dr. Garrett Rentier

2. Address: 8897 SW 29th St.

3. City/State/Zip: Topeka KS 66614

4. Phone Number: (785)222-8777 Ext:

5. Fax: (785)222-8778 6. Email Address: grentier@pediatricstopeka.com

Insurance Information 7. Primary Insurance: Den and Ken Insurance

8. Secondary Insurance: All Farm Insurance

9. Signed Release to Bill Insurance: Yes No

10. Signed Doctors Orders: Yes No

11. Medicaid/KanCare ID #: N/A

Child Health Information 12. Summary of childs health status based on review of pertinent records (please share pertinent information): [Birth History (weight, gestational age, etc.), Medical Conditions or diagnoses (i.e. allergies), Illnesses, Hospitalizations, Medications, Oral Health, Health Precautions and Safety Issues, Family History, Other:] Within the past 6 months Kicho has been diagnosed with Spinal muscular atrophy (SMA) based upon concerns about Popo and Lan's concerns about her developmental progress. She has been placed on a number of medications, lithium carbonate and morphine, to help manage the progress of her SMA. Immunization up-to-date: Yes No N/A

Kan Be Healthy up-to-date: Yes No N/A

Nutrition Summary:

13. Weight 18 lbs Length 20 inches

14. Follow-up Needed Yes No

15. Results/Concerns: Kicho's weight is being followed by Children's Mercy as it relates to her diagnosis


16. Date tested/screened: 8/16/2012

17. Results/Concerns: No concerns at this time

18. Date re-tested/screened:



19. Results/Concerns:


20. Date tested/screened: 08/16/2012

21. Results/Concerns: No concerns at this time

22. Date re-tested/screened:



23. Results/Concerns:

Page 4 of 20

Childs Name: Kicho D. Jung DOB: 02/01/2011 IFSP Date: 02/03/2013


A developmental eligibility evaluation was recently completed with your child and family and ongoing assessment information has been gathered. This information helps us understand your childs developmental strengths, as well as some of the things that are challenging for your child and may be affecting how he/she is able to participate in family and community activities.

This is the summary of what we have discovered so that our plan fits well with your childs developmental strengths and interests. Sources of information for this summary may include conversations we have had with you, observations of your child in daily routines, eligibility evaluations, assessments, and outside reports.

1. Indicate the dates and types of information used to develop this summary (e.g., AEPS, HELP, parent reports, etc.): RBI, HELP, My Child Interest's Activity Plan toolkit

Positive Social Relationships:

This refers to how children relate to those around them - their parents, caregivers, brothers and sisters, and other young children. This includes many different skills such as communicating, showing emotions appropriately and controlling their own behavior. Having positive social relationships also requires young children to follow rules for how to interact, such as waiting for ones turn or sharing.





Going on errands with Lan and Po such as grocery shopping, playing tickle games

visiting relatives/friends/neighbors and singing

Kicho is an easy going child. She enjoys anything as long as she can be with Lan and Po.

As Kichos ability to move decreases it is harder to take her places but she enjoys it immensely, so we would like to still be able to take her places but to

keep her happy and social while we are doing that. ** All developmental domains including: Cognitive, Communication: Expressive and Receptive, Fine Motor, Gross Motor, Self Help and Social Emotional must be addressed within context of the three identified functional areas of development. **

Page 5 of 20

Childs Name: Kicho D. Jung DOB: 02/01/2011 IFSP Date: 02/03/2013 Acquiring & Using Knowledge & Skills:

This refers to the


View more >